COVID And The Brain: 'You Should Be Afraid'
Speaker 1: 00:00 Scientists have only been studying COVID-19 for less than a year, which is why information about it continues to change and evolve. KPBS reporter Beth Huck Amando has always been fascinated by the brain. So she asked UC San Diego health. Neurointensivist dr. Nevas Kyra Angia about how COVID can affect the brain. Speaker 2: 00:22 So I'm someone who's always been fascinated by how the brain works. And I tend to gravitate to pop culture that explores things involving loss of identity and mind control and yes, the zombie apocalypse. So this also means that I love picking the brains of neuroscientists. Like Nevas Karangi of UC San Diego health. Now you specialize in something called neuro critical care. So explain what that means. I'm an ICU doctor that cares for patients with severe brain and spinal cord injuries, like big strokes, brain hemorrhages, brain infections, uh, trauma tumors. So I've done four years of specialty training in neurology and another two sub-specializing in neurocritical care. And now at UCFD I lead a dedicated team of neurosurgeon stroke doctors and nurses in our neuro ICU is to help our patients recover. So COVID-19 is what's known as a novel Corona virus, and that means scientists have only been able to study it for a relatively short time. Speaker 2: 01:23 So remind people what the challenges for scientists and how information can change as there are more patients to study and more time to see what the longer term effects are. Yeah. So any new diseases challenging because there's limited data at first, right? And that may not show the whole picture until more data comes in. We need to document data from thousands of patients before we can trust the patterns we're seeing. And normally it takes years to design studies, recruit patients and perform this study in a scientifically rigorous and ethical way. But now you've got a highly infectious disease that progresses rapidly over days to weeks. So we've got to accelerate that research yet maintain doing it in an accurate and ethical way. We also have to be able to identify patients with the disease, which was initially really challenging because of limited testing. Um, the longer term effects will take time to discover. Speaker 2: 02:21 Uh, so for example, during the Spanish flu pandemic of the early 20th century, nobody knew what the effects would be on babies. So we needed decades of followup to discover what those effects were. And COVID has only been around for less than a year. So decades down the line, we may still be gathering more information. And how does this complicate things in the sense that people seem distrustful of information, but part of the issue is that information is changing as scientists and doctors learn more. So how do you grapple with that and try to get information out there that people will, yeah, the proliferation of media made it challenging even before the pandemic for people to know what was true, but what mitigated that, uh, is usually scientific studies get done over years, time doctors and scientists discuss agree, find flaws. And then with enough, similar studies distill those findings to a recommendation and pass that on to the public. Speaker 2: 03:22 So despite there being many non-scientific opinions floating around on the internet, it used to be pretty easy for your doctor to identify the reasonable conclusion. What makes Cova different is how rapidly it spreads and kills people. So, especially at the beginning, there was no time for those years long scientific studies to happen. So it is understandable. I think at the, uh, at the beginning, when there was little data conclusions were drawn that needed to be revised as more data came in and that made people question, the conclusions we have and questioning is good. As long as when a solid pattern does emerge, like masks decreasing transmission, we need to acknowledge that and put it into action. And that can be hard for people who may have jumped the gun or taken an early stand. So it's easy to see how, as we learn new things that contradict what we knew before that this could so distrust among the public, Speaker 3: 04:20 You a, has seen a steady flow of COVID patients. What are those numbers like? And how does that compare to anything else you've experienced? Speaker 2: 04:29 We've been carrying for about 30 to 50 COVID in patients per day, since March, about 25 of which are on a ventilator in comparison during flu season, we have on average three patients on a ventilator per day. So no, this is not like anything we've seen before Speaker 3: 04:47 When this began, people were referring to COVID as something like the flu, why has this comparison proven to be an accurate? And what would you say is a better way to look at the disease? Speaker 2: 04:57 Well, it's inaccurate because everybody has some immunity to the flu because we've all gotten the flu at some point or had the vaccine or both. Uh, this means that when we get it again, our symptoms may be so mild. We may not even notice it, but because the world has very little immunity to this new virus, many more people are becoming symptomatic with more severe disease. And that maybe one of the reasons why the current U S mortality rate for recorded COVID cases is 3.3%. And for flu is 0.1%. Another reason why COVID might be deadlier is because on autopsies, we not only see evidence of the virus in the lungs, but we also see it in the brain, kidneys, heart intestines, and even the lining of the blood vessels everywhere in the body, which can lead to life threatening clots, uh, that, that could explain why patients with severe COVID are sustaining damage to all their organs, much more than patients. Speaker 3: 05:58 And this kind of brings us to the part of the discussion that I am most interested in, which is how COVID affects the brain. Cause this is something that initially was not being talked about. So what are the ways that COVID can attack the brain and how does it affect the brain and nerves? Speaker 2: 06:15 The thing that's tragic and fascinating about COVID is it can affect the brain and nerves in so many different ways. For example, the damage it causes to blood vessels. I mentioned earlier can lead to strokes and brain hemorrhages in up to 6% of hospitalized patients, low oxygen levels caused by the lung and heart injury can damage the brain and the inflammation itself from the infection can affect the brain and the nerves causing confusion and delirium in the majority of patients with severe COVID, it can also directly and affect the nervous system in a mild cases. It can cause loss of taste or smell or in severe cases. It can cause meningitis. We've also seen it cause an autoimmune reaction where the body's antibodies to the virus accidentally attack the brain and nerves. And that can cause life-threatening issues like brain swelling and Keon Baret syndrome. And finally, there are psychiatric symptoms that are being reported where seeing people with hallucinations, even psychosis, uh, even after mild Cova disease, um, which couldn't be from brain involvement. And then there's the anxiety, depression and PTSD PTSD due to the psychological trauma of being hospitalized with a frightening disease. Speaker 3: 07:33 Yeah. So this proves to be more scary than a horror film or than zombies themselves. So is this disease seeming to do something that's new and that's never been seen before, or is it just affecting the body in ways that are causing these neurological problems? Speaker 2: 07:53 So it's not that these things have never been seen before. We've seen them to very small degrees in, uh, in other viral infections, but I think what's different about COVID is you've got no immunity in most people. And so the effects are, uh, are proving to be very severe and much more common, um, in the nervous system than we're used to seeing in other viruses, because most people have some immunity to those viruses. One of the unique things about Cova though, is that effect on the blood vessel lining that causes clots everywhere in the body. This is not something we've seen, uh, from common viruses before. And that's why the effects of COVID seemed to be a more devastating and causing more widespread organ damage than we're used to seeing with other viruses. Speaker 3: 08:49 So can you talk about some of the specific neurological problems that COVID can cause some specific of things you've seen or that have been documented Speaker 2: 08:58 The neurological problems related to COVID can range from mild like headache or loss of taste and smell, which are very common in symptomatic patients to more concerning things like difficulty concentrating or thinking which people are calling brain fog, uh, to confusion and delirium. And then there are the life threatening complications that we've seen, uh, strokes from those blood clots. I talked about brain swelling, seizures, coma from infection and inflammation of the brain, uh, paralysis from auto-immune attacks on the nerves. Uh, what I'm seeing most commonly is delirium in the very sick COVID patients. And we've seen a number of strokes as well, both of which can have permanent consequences. And although they happen more frequently, the more severe the patients cope with symptoms, it's important to note that these neuro emergencies can even happen to patients with mild respiratory symptoms. We've seen some young patients with minimally symptomatic COVID with no stroke risk factors come in with devastating, large strokes. Speaker 3: 10:04 And what kind of symptoms are there in the sense of how can you tell if you might be having some of these neurological complications due to COVID? Speaker 2: 10:13 So one of the ways to remember the symptoms of stroke is the mnemonic be fast, be for sudden balance problems, E for sudden eye or visual problems F for facial drooping, a four arm weakness S for speech problems, and T is time to call nine one one because we have excellent treatments for stroke that can return up to 70% of patients back to a functional life, but they only work if they're started within hours of symptom onset, uh, 2 million neurons are dying every minute you're having a stroke. So that's why it's so important to call nine one one immediately. And that's not an exhaustive list of all the symptoms that could be indicative of neuro complications. Uh, if you see somebody convulsing confused sleepier than usual with a bluish tinge to their face, or just generally not acting like their normal self call nine 11. Speaker 3: 11:07 So are the neurological complications coming mostly from, or by COVID causing strokes and, and, uh, you know, depriving the brain of oxygen or does the virus actually just directly attack brain cells? Speaker 2: 11:24 So the problem with this virus is it can do both. So there are plenty of reports of meningitis and encephalitis or inflammation of the brain from the virus infecting the brain. Um, we also know that even in minimally symptomatic patients, uh, when they, uh, have an MRI, they can demonstrate evidence of inflammation of the brain, even if they don't have neurologic symptoms. So the exact number of patients that's, uh, that are having, um, neuro invasion is unclear, but because an early symptom of COVID is commonly the loss of smell and taste, which, uh, is carried by the nerve from the nose that goes directly to the brain. The olfactory nerve, we are concerned that direct invasion of the neurosystem is happening in a much larger percentage of patients than we would normally expect with, with, uh, with a virus like this. The stroke complications are happening in about 6%. Um, depending on the study that you read of is hospitalized COVID patients and they happen more frequently. The more severe the COVID is. So, uh, those, um, complications, although less frequent are, uh, are, are pretty devastating. Speaker 3: 12:53 So for you as a scientist, the complications coming from a stroke are kind of a very predictable sort of thing that you've seen before, but the way in which the virus may be affecting the brain cells directly is the part that's very new and kind of uncharted territory. Speaker 2: 13:10 I wouldn't say it's uncharted territory, because we do know of other viruses that, uh, that invade the brain and some even more aggressively like the herpes virus. Um, but it's because of the large number of patients that are getting COVID. We are seeing many more patients with neuro complications than we do with say the flu or with other viral infections. Speaker 3: 13:40 Now, another thing about COVID is I've read that about 80% of the people who get it will recover without excessive care. And it seems like this is kind of contributing to how potentially dangerous it is. So at this point in time, we don't yet know like what longterm effects there might be for people who may have even just had a mild case, correct. Speaker 2: 14:03 That's right. What's deceptive is even if you don't end up in the hospital for your respiratory symptoms, you might have other neurologic symptoms that linger for a long time after an initially mild COVID infection, many patients have described weeks to months of persistent fatigue or the inability to think clearly loss of smell or taste or other vague symptoms like intermittent tingling, or erratic pulse or blood pressure. And on MRI, some patients with no symptoms except for loss of smell, have brain inflammation. And for some of those patients, their symptoms are still ongoing. So we don't know how long they will last or what percentage of people will get them, or whether there are other longterm effects. That's why there are studies going on to investigate those longterm effects. Uh, one is the covert symptom study that you can sign up for online and tracks your symptoms through an app. There's another one in San Francisco that will track patients for two years, and there are neuro COVID clinics. Now opening up to help patients. We have one at UCFD that patients can contact if they're experiencing any post COVID neuro symptoms. So what might be the dangers of these Speaker 3: 15:17 Complications from COVID as we kind of move, Speaker 2: 15:21 But for the more severe neuro complications of COVID like stroke or Keon Baret, the risk of death or permanent disability is very real. For example, with stroke, mortality is around 20% and permanent disability, um, happens to about 50% of stroke survivors with Yon Baret up to 20% of patients are left with significant disability. And even if you don't have visible damage to the brain from COVID just being in the ICU and being delirious puts you at high risk for what's called post intensive care syndrome or pics, which can lead to persistent fatigue, cognitive problems, similar to Alzheimer's and psychiatric problems like PTSD for years, following discharge from the ICU, we know that these symptoms occurred in about 30% of hospitalized, SARS patients. And one recent French study suggests it's occurring in around 30% of COVID patients requiring ICU care as well. There are also some yes, Speaker 3: 16:23 Psychiatric complications that have come from COVID. Can you discuss some of the specifics about that? Speaker 2: 16:28 Yes. So last month there was a, a publication describing multiple patients with otherwise mild COVID who experienced visual hallucinations, auditory, hallucinations, OCD, like behaviors, uh, anxiety, depression, and PTSD. Um, so this could be due to injury to the brain, or it could also be due to the very real psychological trauma of being hospitalized and isolated with a scary disease. Speaker 3: 17:00 Do you have, COVID talks about it in terms of numbers, how many might get sick? How many might die and are these patients Speaker 2: 17:06 Larger, small, but why should we care about them? Speaker 3: 17:09 Even if some of the numbers being discussed are not Speaker 2: 17:12 Large, although the percentages of people that are hospitalized and die of COVID may seem small. The problem is the total number of patients infected with COVID in the U S is very high making the absolute number of patients that will develop neuro problems. Also very high. So according to the CDC, almost 5 million Americans have been infected and over 40,000 hospitalized. So if 6% of our hospitalized COVID patients suffer strokes, that's 2,400 patients having strokes. And if a third enter the ICU and half get pics that's thousand people. So that's a lot of pain and suffering and a lot of money for rehab and nursing facility care that will be needed. So that's why it makes sense not to treat these complications after they occur, but to prevent yourself from getting COVID and the first place, which is why wearing your mask and social distancing is so important. Speaker 3: 18:10 Well, and it also seems like another potential thing to consider is that we don't know how many people have come down with the disease might end up having longterm health issues that will have a burden on the health care industry in years to come. Speaker 2: 18:27 Absolutely. Um, you know, for a stroke, for example, we know that, uh, the U S spends $34 billion per year on caring for stroke patients. So patients that suffer neurological complications of COVID, um, the, at least the more severe ones may have similar disabilities requiring similar amounts of expensive care. So there is a big unknown as to, uh, what amount of pain, suffering, and dollars. This is going to cost. Speaker 3: 18:58 I'm going to bring a little pop culture into this because we did discuss world war Z and its author. Max Brooks talked about COVID when I interviewed him. And he described it as COVID is like the slow moving George Romero's zombies. It's easy to underestimate them. A Bola was like the fast moving ones that everybody was afraid of. And we're quick to kind of mobilize against. So it seems like there's this kind of surreal quality to the current pandemic because so much of life still seems normal, but why should people take this disease seriously? It's true. Speaker 2: 19:35 So much seems normal until you or your loved one contracts. It, people need to take this disease seriously because at best your asymptomatic, but could give it to a vulnerable person who could die. And at worst, you might be one of the unlucky people who develops a disabling or lethal complication. And it's totally true that it's like the slow moving zombies. People are like, Oh, I'm young, I'm healthy. I can prevent the zombies from catching me. That's, there's this same misconception with Cova too, that young, healthy people don't get significant disease, but we have absolutely seen them get severe symptoms. I've seen fit 40 year old nurses and construction workers with no other medical problems die in front of me. And, uh, that is the harsh reality of this disease. Speaker 3: 20:23 And for you personally, I mean, you, you talk about having to witness somebody dying from this disease. How is this affecting you? Speaker 2: 20:31 So the emotional burden of seeing patients die and not be able to see their loved ones as they die is really, uh, very distressing. Um, and it has resulted in a lot of depression and anxiety among many of my colleagues. Uh, and it's also really scary because every day we know we're going into a high risk place where people may be infected. Our daily routine is totally disrupted. When we enter the hospital, we go through this gauntlet of questions to make sure we're not infected. We have to wear a mask and eye protection. At all times, I'm using a Kleenex or my elbow to touch buttons and door handles. We have to stay three feet away from our colleagues. We can't eat or drink with them, which means we're doing a lot of our patient care over teleconference. We can't get really physically close to patients for a prolonged period of time who aren't wearing a mask. Speaker 2: 21:25 And when we see COVID patients, we have to wear head to toe protective gear. Um, when I get home, I decontaminate an outdoor shower as do many of my colleagues. And then I decontaminate all the items. I brought home from the hospital and then wash all my clothes. So there's a lot of things that go into staying safe. And for the nurses who have to be up close to their patients, it is really scary because they can't distance. And although we've been very lucky at UCFD, that we've always had the appropriate PPE. Uh, and very few of our employees have gotten infected at work. It is still terrifying. I've had nurses tell me that they cry every time they go home from work, because they're scared of coming back. Speaker 3: 22:08 And as a scientist, how are you viewing the way the media and particularly social media are handling information? There seems to be quite a bit of misinformation out there, as well as people, not trusting doctors, not trusting the CDC or the who, but believing in any study that might suggest a cure that somebody shares on social media. So do you feel that this kind of an atmosphere or mood is something new that you haven't seen before? Is it a challenge for you to get good information out there? Speaker 2: 22:42 So, uh, it's not new, unfortunately, um, during the Spanish flu pandemic, for example, people were also desperate. Some were a Hawking quinine as a treatment, which it's not, uh, for the flu and protesting against mandatory as flaws then as well. But as it became clear that quite I didn't work and mask wearing, did people eventually came around as I'm optimistic, they will today. So yes, it is a challenge to get good information out there because it takes time to do good studies and then get the answers out there in a way. So people know they're legitimate, but what's important for people to understand is that scientists are still going through the process of doing those studies and we need patients help to participate in them. So we can understand this disease. Speaker 3: 23:33 And just to briefly return to world war Z. Was there anything in that book that you felt people could actually learn from, or that was predictive of our current pandemic in a way that lends some into it? Speaker 2: 23:46 Yeah, so I think there are a number of things that max Brooks got right in his MB apocalypse book. So one of the most salient ones I think is because no one wanted to believe that a serious pandemic was occurring in the book. There was a delay in using the right tactics to combat it, which resulted in a lot of preventable death and suffering. So while Cove is not a zombie apocalypse, it would be great if we could learn from world war II, take this pandemic seriously and initiate appropriate containment tactics to prevent it from snowballing, as opposed to the book, we don't have to lead to Canada to escape this pandemic. All we have to do is wear a mask and social distance. What do you think Speaker 3: 24:29 It needs to be done moving forward? What kind of treatments are there, or what kind of things are you seeing that might be helpful or hopeful to people? Speaker 2: 24:37 And so I'll, I'll take your question in reverse, if you don't mind, um, in terms of treatment for severe COVID, there are a number of promising medications under investigation, but of course the best treatment will be to prevent getting it in the first place. So there are multiple vaccine trials going on worldwide. Um, UCFD is participating in many of those medication and vaccine trials, uh, for treatments for the neurologic complications, because these are all conditions we've seen before. We already have excellent treatments for stroke. For example, we have clot busting drugs and procedures to remove brain clots that can return folks to a functional life up to 70% of the time, as long as they reached the hospital within hours of their symptoms. And we also have excellent neurocritical care treatments for the other conditions, but to get them may require access to a hospital like UC SD that has neuro critical care, resources and specialists. Speaker 2: 25:34 So moving forward, if we can all try to be patient and continue to wear our masks and social distance, so we can slow the pace of infections, it will give us time to do the research, find out what really works and help make sure there's an ICU bed for you or your family. If you need it. This, I think is a, is a team sport. One of my colleagues said, team human against team virus. And the game is changing as we go on, but it's like that saying United, we stand divided. We fall. If we all work together, we can beat this thing. Speaker 3: 26:10 And because there's so much information out there and so many sources people can go to, how can people keep up with changing or updated information? And what would you suggest is a good way to kind of test the information or determine whether something is actually valid or worth listening to? Speaker 2: 26:29 Yeah. So for physicians, um, besides reading the literature, as it comes out, a lot of us are constantly discussing what we are seeing in real time with our colleagues across the world. Um, for the general public, the CDC and County websites on COVID-19 are pretty comprehensive and well updated. A UCS D and other academic hospitals also have great COVID websites with a lot of resources and can direct you to local clinics, hospitals and nurse lines, where you can ask for help. Um, in terms of determining what, uh, information is solid, the best way to figure this out is to ask your physician. All right. Well, I wanna thank you very much for taking some time to talk about COVID and COVID in the brain. Thanks. It's been a pleasure. Speaker 1: 27:21 That was dr. Nevas car and JIA speaking with Beth Mondo.